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Mindful Recovery from Depression

By Zindel Segal

Mindfulness isn't a skill that comes naturally. If you want to anchor your attention to what's happening in the present moment, you must actively engage your mind's natural tendency to fly all over the place. At the heart of mindfulness lies, not a desire to suppress this inner restlessness, but a nonjudgmental curiosity about it, and a willingness to simply observe it as it happens. Making friends with our attention--not beating it (and ourselves) up when it drifts from its intended focus--helps teach us how to deal with other deviations from perfection in ourselves and others. When we're berating ourselves for falling short of our own expectations, mindfulness practice teaches us to bring the same type of gentle awareness to these self-denigrating thoughts and feelings in our everyday lives.

This perspective is definitely at odds with traditional therapeutic ideas about insight and change. The prevailing clinical understanding of meditation's effectiveness emphasizes that it teaches patients how to relax and lowers their chronic physiological hyperarousal. But the point of mindfulness training is to help people sustain an alert, flexible, and focused attention, rather than to relax, though relaxation occurs as a secondary consequence. Also, in contrast to relaxation training, which aims for the release of tension, mindfulness has no predetermined endpoints or goals. Whether we experience ease or difficulty is less important than greeting each sensation with awareness and curiosity.

But mindfulness practice seems to break an even more entrenched rule of standard therapy, confounding clients' expectations in the process: instead of talking about and analyzing inner experience, mindfulness relies upon simply becoming aware. The shock of reversing the standard clinical sequence--in which awareness of emotional states and hidden thoughts is supposed to increase after analysis or discussion--seems to make patients more receptive to learning alternative ways of relating to depressive thoughts and affects, too.

Medications or Mindfulness

One of the most challenging and widespread issues in clinical practice is depression. A recent landmark study of more than 4,000 depressed patients who were taking different antidepressants (www.star-d.org) found that 70 percent of the subjects required up to four medication trials before finding one that helped them. Only 30 percent benefited with the first medication they tried. The good news here is that drugs can help, and people with depression shouldn't give up if their initial medication trial doesn't succeed. The picture is darker, though, when we look at how long any of these gains were maintained. Some 40 percent of patients who did well with their first antidepressant suffered a relapse, while the relapse rate of those who were helped only on their fourth try was a dismal 71 percent.

In light of these results, it's hard to subscribe to the overheated hype advanced by drug advocates that pharmacological treatment of depression is sufficient. While undoubtedly helpful for relieving acute depressive symptoms and facilitating a return to work, antidepressants don't actually teach patients skills for addressing the myriad personal and interpersonal stresses that keep them stuck in depressive cycles, nor do they offer protection against depression's return once the drugs are discontinued. In fact, large surveys of depressed patients in the community indicate that, regardless of whether recovery is spontaneous or treatment induced, depression returns to peoples' lives at alarming rates. Within the first year, for example, 50 percent of people are at risk of relapse, and if someone has suffered at least three past depressive episodes, the rate increases to 70 to 80 percent within three years. What this suggests is that we may need to stop hoping that one "big-bang" miracle drug will end depression once and for all, and begin thinking of better ways to prevent episodes and cope with them when they occur.

Mindfulness, Cognitive Therapy, and Mood Disorders

More than 20 years ago, Jon Kabat-Zinn and his colleagues at the University of Massachusetts Medical Center faithfully adapted the teaching of mindfulness meditation for use in modern medical settings, and created something of a revolution along the way. Called Mindfulness Based Stress Reduction (MBSR), their program of meditation training--taught without a particular religious or philosophical belief as a basic awareness technique that anyone could use--has helped many thousands of people with chronic medical problems find peace, calm, and joy, even while suffering from pain, inflammatory bowel disease, asthma, and heart disease--all of which occur episodically, waxing and waning like depression. The basic message of the program was that all of us, whether we suffer from medical or emotional problems or simply the difficulties of ordinary human life, frequently find ourselves swept away by currents of unpleasant thoughts and feelings that hijack our minds. Because we're "somewhere else" in our heads--anxiously anticipating the future, regretting the past, obsessed with our pain, or just numbed out--we lose control of our lives and the vividness of the present moment. Not only does being more directly present to what's happening right in the moment enrich our ordinary lived experience, it helps us become more aware of choices and possibilities that had previously eluded us.

The program for depression my colleagues Mark Williams and John Teasdale and I developed, Mindfulness Based Cognitive Therapy (MBCT), integrates the eight-week group approach of MBSR with basic principles of cognitive therapy. Participants in MBCT, like those in the MBSR program, meet together to practice various forms of mindfulness meditation--the body scan, mindful stretching and walking, and alternating the focus of attention by shifting between mindfulness of the breath, the body, ambient sounds, and thoughts. Group members learn informal practices that encourage close attention to the ordinary rote experiences of daily life as a hedge against depression--eating a meal mindfully, monitoring the physical sensations while brushing teeth, noticing how tightly one grips the wheel of the car while driving.

How does focusing on everyday physical actions help participants take a wholly different approach to the endless cycles of mental strategizing that often drive depression's return? When people get lost in thoughts or try to jettison their feelings, they typically pay very little attention to the physical sensations from their bodies. Yet, those sensations provide immediate feedback about what's going on at an emotional and mental level. The act of observing our bodies is good training for when we feel bad--anxious or depressed--because it gives us a kind of emotional detachment, which acts as a stable emotional platform, preventing us from being overwhelmed by our feelings.

Of course, it can be difficult to be mindful at just the times when mindfulness would be most helpful. When we're faced with a crisis, or when we're emotionally crashing, and there's no time to gather our thoughts, mindfulness can seem like a hopeless luxury, impossible to achieve. So, we created a tool specifically designed to bring mindfulness into everyday life at exactly those moments when someone's mood seemed to be heading south in a hurry. This emergency tool is a mini-meditation called the three-minute breathing space, in which the entire teaching of the MBCT program is concentrated in three brief steps: 1) Opening to experience as it is, 2) Gathering attention to a focus on the breath, 3) Becoming aware of the sense of the body as a whole. Because the three-minute breathing space allows people to quickly incorporate manageable bits of mindfulness training when they need it most, many group members have singled it out as the most useful feature of the entire course.

The cognitive therapy aspects of MBCT include psychoeducation about depressive symptoms and the dark thinking styles that often accompany them. We teach participants to look at their negative thoughts as creations of their minds and not facts--not real reflections of themselves, but part of a larger package of depression. If, for example, they can regard a thought like, "I really am a loser!" simply as an artifact of their own minds, and say to themselves, "Oh there's another one of my put-downs of myself," they can rob it of its power to sink them in a tide of self-loathing. If certain thoughts or beliefs still have a strong pull on awareness, participants practice questioning them with an attitude of investigation, curiosity, and kindness.

To date, MBCT has been evaluated in three randomized clinical trials, each showing a significant protective advantage for patients receiving the treatment. Recently, the United Kingdom's National Institute of Clinical Excellence (NICE) endorsed MBCT as an effective treatment for relapse prevention. Research has shown that people who've experience multiple episodes of depression can reduce their chances of having it return by 50 percent with this method.

"I Can Be with It and Don't Have to Fix It"

Joanne, a dark-haired woman in her early thirties, worked as an account alongside her husband, a bankruptcy lawyer in a joint practice, and they had two children. She'd battled mood problems since her parents' divorce when she was 25. Six months earlier, she'd begun waking frequently at night and feeling weepy at work. Her physician diagnosed depression and started her on 30mg of Cipralex, which had helped. Nonetheless, having been through these episodes three times, Joanne wondered how she could prevent more relapses.

At our individual meeting before the MCBT group started, Joanne was engaging and open, and I had the sense that she was a real "doer," who led with her competence and saw setbacks merely as problems to be solved. She hoped taking the course would help her "get a better handle" on her emotions.

Joanne attended regularly and was supportive of other group members when they spoke. Early in the program, she described enjoying the relaxation that came from lying or sitting still for an extended period of time.

In a session midway through the program, she volunteered that her mother-in-law had come over for Sunday dinner and been critical of the fact that there were toys all over the place and that the kitchen was littered with pots and pans. As Joanne felt herself go into a slow boil, she also remembered that this was exactly the sort of situation the group had discussed as being ripe for mindful exploration. So, instead of allowing herself to be engulfed by resentment and tension, she decided to attend to the sensations in her body and spent a few moments just noting her thoughts and feelings. What happened next confused her. In the past, particularly when she witnessed her parents' incessant fighting, avoiding her feelings of fear and despair had helped her stay efficient and not become overwhelmed. Now, instead of going away, the thoughts and sensations became stronger. She felt a constriction in her throat, some tightness in her forehead and was conscious of thinking, "I wish she'd just get out" and "Nothing is ever good enough for her." This wasn't what she'd bargained for.

The group listened to Joanne recount her struggle to regain her emotional footing as the dinner progressed. Sonia, a retired nurse, asked her if she'd ever thought that she might just stop fighting with her emotions when she was upset and accept that they're already there. Sonia said that on the few occasions when she'd been able to do this, she'd been surprised to observe how her feelings had waxed and waned. But Joanne was highly skeptical of an approach so contrary to her own way of doing things.

In the next session, something interesting happened. I'd just finished guiding the three-minute breathing space, and Joanne was the first to speak. She said that during the exercise, she was definitely aware of physical sensations of sadness and disappointment--a pressure on her chest and moistness around her eyes. Her suspicion was that they'd been there all along. I asked her, following the steps in the exercise, to allow the feelings to be there and then move her attention to the breath before expanding awareness to her body as a whole. Joanne said that the sensations were still there, but they'd changed: they hadn't become better or worse, but she'd become aware of an ebb and flow in their texture and feeling. I offered that she was noticing something about the qualities of the sadness. Yes, she said, adding that she could see the value in noticing that her feelings changed on their own, and that she didn't have to fix them. It was almost like watching clouds form and dissolve across the sky--a phenomenon she found at once interesting and calming. With a sense of surprise, she said she now understood how she could be with her sadness and not be afraid of it.

I ran into Joanne a year later at one of the monthly mindfulness classes for graduates of the MBCT program and asked her how she'd been. She told me that her depression hadn't recurred and that when she felt overwhelmed by worries or endless tasks, she still relied on the three-minute breathing space to return to a calmer, steadier sense of "now." So when something raised her old sense of anxiety, she no longer panicked. Rather, she steadied herself with the breath and attended to wherever in the body these feelings were making themselves known. She said she felt more in control of her feelings and experienced a greater sense of freedom at the same time. She now was aware that she didn't have to be carried away by sadness or disappointment.

What's Your Practice?

This question to a therapist who teaches mindfulness may be either challenging or merely curious. But the answer you give has enormous bearing on how effective you'll be with your patients. Participants in our program must ultimately learn about mindfulness through their own practice, of course. But it's critical for people already distressed and feeling overwhelmed to have an instructor who can embody these practices in his or her own interactions with them. Unlike manual-based therapies, which don't require the clinician to have undergone the procedures, mindfulness training requires instructors to participate alongside the patient, not just give instructions.

Still, developing a personal mindfulness practice isn't easy for anybody in our fast-forward society. Finding time in a busy schedule, or perhaps getting up 45 minutes earlier than usual, quickly eliminates the uncommitted. To help people discover that difficult or unwanted thoughts and feelings can be held in awareness and seen from an altogether different perspective is virtually impossible without having gone through the same experience yourself. In a sense, we're engaging in a lifelong pursuit less for our patients than for ourselves, so that we can be more deeply present with them while we're carrying out our clinical work.

If we can approach this practice in the same spirit that we ask of our patients and trainees, we'll find our own way--as they must--to a place of true beginning. From there, the rest takes care of itself.

Zindel Segal, Ph.D., is the Morgan Firestone Chair in Psychotherapy and professor of psychiatry and psychology at the University of Toronto. His latest book is The Mindful Way Through Depression. Contact: Zindel_Segal@camh.net. Letters to the Editor about this feature may be e-mailed to letters@psychnetworker.org.

The following Networker U Courses on this subject are available at www.psychotherapynetworker.org: